Midwest June Newsletter 2022

Wishing You a Happy and Healthy Summer

It’s hard to believe summer’s already upon us. As the weather warms and we say goodbye to rainy spring days, we want to thank you – as always – for all you do to help keep our members healthy. We rest easy knowing that they have such hard-working, talented providers to take care of their health and well-being. As June folds into July and beyond, we wish you and your staff the best start to summer 2022.

As It Relates to You

Key information for you and your staff.

Remember to Keep Your Provider Information Up to Date

The information in our provider directories is key to making sure patients – both existing and new – can easily reach you. Our members use the directories to search for new providers, get directions to clinics and find contact information to schedule appointments. CMS and departments of insurance require that providers review and update their information in a timely manner or whenever there are significant changes.

Please remember to use our new forms to update your provider information or to add a provider to your practice. You’ll find the forms in the Provider Resources section on Provider.HealthAlliance.org. If you’re adding providers to a currently contracted practice, please use the Provider Addition form – along with attaching the appropriate provider application and supporting documentation – not the Prospective Provider form.

Please send all provider updates to Provider.Updates@HealthAlliance.org. Your provider relations specialist will continue to be your contact for all other inquiries. Thank you so much for your help in keeping your information up to date.

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Help Us Move the Needle

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

Men’s Health Month

It’s a fact: on average, men in the U.S. die five years earlier than women, and they die at higher rates from the top three causes of death (heart disease, cancer and unintentional injuries). June is Men’s Health Month, and the U.S. Department of Health and Human Services (HHS) wants providers nationwide to take action. Here’s what they suggest you do:

• Raise awareness about men’s health, the specific issues men face, and the best ways to seek education, prevention and treatment.
• Encourage men and boys to focus on healthy living practices – such as exercising, eating healthy, not smoking, staying up to date with their required preventive care (such as the HPV vaccine for boys age 11 to 12) and getting the help they need for their mental well-being.
• Teach parents, guardians and caregivers to model good health behaviors for the boys and men in their lives.
• Share and promote the HHS’ Five Plays for Men’s Health. Download, print and display – or share digitally – the great images (in both English and Spanish) found here.
• Have your office, hospital or clinic participate in Wear BLUE Day – an initiative of the Men’s Health Network – on Friday, June 17, to help raise awareness of the importance of men’s health.

Finally, visit this webpage – and scroll to the bottom – for a wealth of links and resources on men’s health and men’s health disparities. This month and beyond, help men live longer, healthier lives. We’re grateful for your help.

Help Your Patients Quit Smoking

Did you know that most of our health plans cover smoking cessation medications and coaching for our members?

Our smoking and vaping cessation program, Quit For Life^®, is a great first step. Quit For Life is the nation’s leading tobacco cessation program, complete with one-on-one support from a Quit Coach^®. Here are some more details:

• Members can enroll once every 12 months (equals two quit attempts).
• They can use a combination of different nicotine replacement therapies (NRT). There is no pharmaceutical copay if accompanied by a prescription.  Members should call the number on the back of their ID card to verify if their plan covers NRT.
• They can get patches, gum and lozenges through our own pharmacy without a prescription, when we mail directly to them.

And they also can get:

• Behavioral support that lasts six months.
• Help understanding their medication.
• One-on-one coaching by phone.
• A personal quit plan made just for them.

Tobacco harms far too many lives. We ask for your help in encouraging your patients to get the support they need. Let them know about this covered program, and point them to this webpage to learn more. Together we can help them Quit For Life.

Yearly Nephropathy Screenings
for Patients With Diabetes

Did you know that 20% to 40% of people diagnosed with diabetes also develop kidney disease? Or that 40% to 50% of all diagnosed cases of end-stage renal disease (ESRD) are related to diabetes? Despite these alarming stats, many people with diabetes do not get their recommended yearly nephropathy urine screenings. As providers, you can help ensure your patients stay up to date with this vital screening, so kidney damage can be detected early and interventions can be started if needed.

For all of your patients with diabetes, please remember to:

• Review their health record and order a nephropathy screening if it’s due. If it’s not due yet, give them a reminder of when it’ll be due.
• Educate them about how symptoms of kidney failure usually don’t occur until nearly all function is lost, which is why yearly nephropathy screenings are so important to their health.
• Remind them to stay within their target blood sugar ranges and keep their blood pressure controlled.
• Encourage them to lead a healthier lifestyle, and to engage in health coaching or care coordination. Our members can call the number on the back of their member ID card or visit the webpage linked above to find out more about these helpful services.

Finally, please see – and make use of – this Kidney Health Toolkit from the National Committee for Quality Assurance. The downloadable Education for Providers gives a quick and helpful overview of how to assess for, monitor and manage kidney disease in your patients – including useful information on how to interpret test results from nephropathy urine screenings.

Thank you – we deeply appreciate all you do to help keep our members healthy.

Help Prevent Shingles –
What To Know About the SHINGRIX Vaccine

Shingles (herpes zoster) is a disease caused by the reactivation of the varicella zoster virus, the same virus that causes chicken pox. Shingles is characterized by a painful rash and the most common complication – in spite of treatment – is chronic pain in the affected area (post-herpetic neuralgia). Cases of shingles increase sharply with age, being more common in those over 50 and affecting up to 50% of people 85 and older. Along with age, underlying diseases like diabetes and chronic obstructive pulmonary disease (COPD) also increase the risk of developing shingles, along with its severity and impact.

The Centers for Disease Control and Prevention (CDC) estimates that 25% to 33% of adults will get shingles at some point in their life. Of these, one-third will develop complications – most commonly nerve pain that lasts for months or even years after the rash heals.

To prevent shingles – and its related complications – the CDC recommends the vaccine called SHINGRIX (recombinant zoster vaccine). For detailed information about all the CDC’s specific recommendations regarding this vaccine, visit this webpage. Here are some of the highlights:

• The CDC recommends two doses of SHINGRIX, separated by two to six months, for immunocompetent adults age 50 and older.
• For these individuals, SHINGRIX is recommended even if they’ve had a prior episode of shingles; and even if they’ve had a prior dose of ZOSTAVAX® (a shingles vaccine no longer available in the U.S.).
• It’s not necessary to screen, either verbally or by laboratory serology, for evidence of prior varicella infection.
• For immunocompromised adults age 19 and older, the CDC recommends two doses of SHINGRIX, with the second dose typically given two to six months after the first. However, for those who’d benefit from completing the series in a shorter period, the second dose can be given one to two months after the first.
• For those who’ve previously had shingles, there’s no specific amount of time you need to wait before administering SHINGRIX. However, do not give SHINGRIX to patients who are currently experiencing an acute episode of shingles.
• SHINGRIX should not be given to someone with a history of severe allergic reaction – such as anaphylaxis – to any component of the vaccine or to a previous dose of the vaccine.
• For those who are pregnant, you should consider delaying vaccination until after pregnancy.
• Those with a minor acute illness, such as a cold, can receive SHINGRIX. However, those with a moderate or severe acute illness should usually wait until they recover to get the vaccine.

HEDIS Quality Measure –
Follow-Up Care for Children Prescribed ADHD Medication (ADD)

By working together, we can improve health outcomes for your patients. The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of standards that helps us together assess the care patients receive. This article gives you information on the HEDIS quality measure for follow-up care for children prescribed ADHD medication (ADD).

Why is this measure important?

More than 1 in 10 American children have been diagnosed with ADHD (attention-deficit/hyperactivity disorder). It’s one of the most common mental health conditions among children, and it affects their ability to concentrate, remain focused and more. Fortunately, medication – when properly managed – can control symptoms of impulsiveness and hyperactivity, and help patients with their ability to concentrate and remain focused. It’s therefore key that medication is prescribed and managed correctly, with this being monitored by a pediatrician who has prescribing authority.

What is the measure?

HEDIS looks at – and reports – the following rates. Both assess follow-up care for children prescribed an ADHD medication.

• Initiation Phase: Assesses children age 6 to 12 who were diagnosed with ADHD and had one follow-up visit with a practitioner with prescribing authority within 30 days of their first prescription of ADHD medication.
  Note: This first follow-up visit must be in person with the prescribing provider. It cannot be a virtual (telehealth) appointment.
• Continuation and Maintenance Phase: Assesses children age 6 to 12 who had a prescription for ADHD medication and remained on the medication for at least 210 days, and had at least two follow-up visits with a practitioner in the nine months after the Initiation Phase.
  Note: These later two follow-up visits can be virtual (telehealth) appointments.

Final Thoughts

ADHD is a condition that can be managed. Make sure your patients – and their parents or guardians – know how important all three follow-up visits described above are to their care and treatment. Medication alone isn’t enough, and these follow-up appointments are key. It’s also important they get them within the time described above, rather than delaying them for later dates.

Thank you for all you do every day to give your young patients the best possible care. We’re deeply grateful for all your efforts.

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Coding Counts:
Coding and Documenting Rheumatoid Arthritis

Supporting documentation and accurate coding are key to making sure your patients receive the care they need. Failure to document persisting conditions on an annual basis impacts your patients, fellow providers and our organization. Here – to help you and your staff – are some helpful documentation and coding tips for rheumatoid arthritis.

Rheumatoid arthritis (RA) is an autoimmune and inflammatory disease that can affect joints and other organ systems.

Avoid documenting “inflammatory arthritis” when treating rheumatoid arthritis, as this terminology only supports coding a diagnosis of “other specified arthritis,” per the American Hospital Association Coding Clinic.

Children diagnosed with juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis) still carry a diagnosis of juvenile rheumatoid arthritis into adulthood and should be coded as such, when applicable.

Important documentation elements for rheumatoid arthritis:

• Site(s) and laterality.
• Positive or negative for rheumatoid factor.
• Type (e. juvenile, Felty’s syndrome).
• Manifestations of disease (e. organ, system involvement, bursitis, nodules, myopathy, polyneuropathy).

Thank you for your help with accurate coding and documentation. We’re grateful for how hard you work and all you do for our members’ health. For even more coding tips, watch these short videos we made just for you and your staff. And visit our Coding Counts page for even more helpful resources.

Reference for this article: Sheri Poe Bernard, CCS-P, CDEO, CPC, CRC. Risk Adjustment Documentation & Coding. American Hospital Association Coding Clinic.

Two Important Reminders

We know you’re busy and deal with a lot of paperwork. Here are two important reminders to help you correctly submit claims.

Full Member Number Required

Just a reminder that claims will be rejected/returned if you do not submit the full 11-digit member number (without spaces). This requirement is for both electronic and paper claims. We continue to see claims submitted with just a nine-digit member number, and others submitted with 11-digit numbers with spaces. For example, member number 99988123401 is being submitted as 999881234 or 999881234 01. Both of these formats are incorrect, and we can’t accept them. Our systems can only accept the full 11 digits as 99988123401, or with a hyphen as 999881234-01.

Submitting Corrected Claims

Corrected/replacement claims must be filed with the accurate frequency code or bill type. We’ve historically attempted to identify inaccurate submissions and process the claims manually, but we’re no longer able to accommodate. Effective August 1, 2022, corrected/replacement claims without proper coding will be denied as duplicate claims, and resubmission will be required. Please refer to AMA CPT guidelines and/or CMS for guidance on proper billing procedures.

Prior Authorization Requests – Important Reminder

When submitting prior authorization requests to us, do not simply put “see EMR for clinical information” (or anything similar to this). You need to fill out/supply the actual information on the request. While having EMR is an advantage, with our strict turnaround timeframes set by government mandates, we’re not able to pull the initial clinical information ourselves. Additionally, our intake staff are nonclinical and are not familiar with what clinical information to pull – this leaves it to the nurses to grab the clinical information, and not all have EMR access and our strict timeframes do not allow for this additional work.

We’re sorry for any inconvenience this may cause, and thank you as always for your care and attention to detail.

Pharmacy Updates

All Plans

Dermatology

Formulary Additions

• Opzelura (ruxolitinib)—Topical short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis (AD) in non-immunocompromised patients 12 years of age and older whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA
    • Medicare—Non-Formulary
• Adbry (tralokinumab-ldrm)—Treatment of moderate to severe atopic dermatitis in adult patients whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary
• Cibinqo (abrocitinib)—Treatment of adults with refractory, moderate to severe atopic dermatitis whose disease is not adequately controlled with other systemic drug products, including biologics, or when use of those therapies is inadvisable. Cibinqo can be used with or without topical corticosteroids.
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Pharmacy with PA
    • Medicare—Non-Formulary

Gastroenterology

Formulary Additions

• Livmarli (maralixibat)—Treatment of cholestatic pruritus in patients with Alagille syndrome (ALGS) 1 year of age and older
  • Formulary placement recommendations
    • Commercial—Tier 6 with PA
    • Medicare—Non-Formulary
• Ibsrela (tenapanor)—Treatment of irritable bowel syndrome with constipation (IBS-C) in adults
  • Formulary placement recommendations
    • Commercial—Non-Preferred Brand with PA
    • Medicare—Non-Formulary

Rheumatology

Formulary Additions

• Saphnelo (anifrolumab-fnia)—Treatment of adult patients with moderate to severe systemic lupus erythematosus (SLE) who are receiving standard therapy
  • Formulary placement recommendations
    • Commercial—Non-Preferred Specialty Medical with PA
    • Medicare—Medicare Part B

Commercial

Dermatology

Criteria Changes

• Plaque Psoriasis Immunomodulator Therapies
  • Added severity for Otezla and age requirement for Cosentyx

Gastroenterology

Criteria Changes

• Ulcerative Colitis Immunomodulator Therapies
  • Added Rinvoq to policy
  • Changed double step edit for Rinvoq and Xeljanz to single step edit

Rheumatology

Criteria Changes

• Benlysta (belimumab)
  • Added exclusion of use in combination with Saphnelo
• Ankylosing Spondylitis Immunomodulator Therapies
  • Added Xeljanz and updated criteria for Cosentyx
• Cosentyx (secukinumab)
  • Reinstated policy to include new indication of ERA
• Polyarticular Juvenile Idiopathic Arthritis Immunomodulator Therapies
  • Changed Enbrel and Kineret from triple to quadruple step edit
• Psoriatic Arthritis Immunomodulator Therapies
  • Added Skyrizi
  • Added dermatologist as prescriber
  • Changed Rinvoq and Xeljanz to single step edit.
• Rheumatoid Arthritis Immunomodulator Therapies
  • Added single step edit to preferred products Rinvoq and Xeljanz
• Rituxan (rituximab)
  • Added the biosimilars Ruxience and Truxima to policy

Other Criteria Changes

• Strensiq (asfotase alfa)
  • Added coverage criteria and MDL
• Behavioral Health Medications
  • Updated criteria for bipolar disorder
• Excluded Drug List
  • Policy has been reorganized to call out exclusion reasoning for different categories of drugs
  • This will clarify which drugs are and are not eligible for appeal when denied due to exclusion

Other New Policies

• Oxlumo (lumasiran)
• Preventive Vaccine Policy

Commercial Tier Changes—Effective 7/1/2022 (affected members have been notified)

• Prenate: Move from Non-Preferred Brand to Excluded
• Xvite: Move from Non-Preferred Brand to Excluded

Please Note: The P&T Committee meets bimonthly and formulary changes and criteria changes can occur during the meetings. Negative formulary changes are made effective on 1/1 and 7/1, while positive formulary changes are effective immediately to better serve our members and providers. Drug coverage and policies in the following categories will be reviewed during the remainder of 2022 and potential changes may be made:

• June meeting: Cardiology, Endocrinology, Pulmonology
• August meeting: Neurology, Psychiatry, Pain
• October meeting: Ophthalmology, Specialty

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